Douglas B. Marlowe, J.D., Ph.D. Treatment Research Institute at the University of Pennsylvania TRI science addiction Targeting Dispositions by Risks &

Douglas B. Marlowe, J.D., Ph.D.

Treatment Research Institute at the

University of Pennsylvania

TRIscience

addiction

Targeting Targeting Dispositions by Risks Dispositions by Risks

& Needs & Needs

Dispositions for Drug Dispositions for Drug OffendersOffenders

Diversion (ARD) Incarceration

Probation w/o verdict

Drug / DWI Courts

Intermediatesanctions

Psychosocial Psychosocial FunctioningFunctioning

$$$$$$ Costs $$$$$$$$

$$$$$$ Costs $$$$$$$$

$$Public Safety

Public Safety RisksRisks

Prognostic RisksPrognostic Risks

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addiction

• Current age < 25 yearsCurrent age < 25 years

• Delinquent onset < 16 yearsDelinquent onset < 16 years

• Substance abuse onset < 14 yearsSubstance abuse onset < 14 years

• Prior rehabilitation failuresPrior rehabilitation failures

• History of violenceHistory of violence

• Antisocial Personality DisorderAntisocial Personality Disorder

• PsychopathyPsychopathy

• Familial history of crime or addictionFamilial history of crime or addiction

• Criminal or substance abuse associationsCriminal or substance abuse associations

Criminogenic NeedsCriminogenic Needs

Substance Dependence or AddictionSubstance Dependence or Addiction

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Substance Dependence or AddictionSubstance Dependence or Addiction1.1. Binge patternBinge pattern2.2. Cravings or compulsionsCravings or compulsions3.3. Withdrawal symptomsWithdrawal symptoms

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} Abstinence is a distal goal



Substance AbuseSubstance Abuse

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addiction





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addiction


Abstinence is a proximal goal}




Collateral needsCollateral needs– Dual diagnosisDual diagnosis– Chronic medical condition (e.g., HIV+, HCV, diabetes)Chronic medical condition (e.g., HIV+, HCV, diabetes)– Homelessness, chronic unemployment Homelessness, chronic unemployment

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addiction






Collateral needsCollateral needs– Dual diagnosisDual diagnosis– Chronic medical condition (e.g., HIV+, HCV, diabetes)Chronic medical condition (e.g., HIV+, HCV, diabetes)– Homelessness, chronic unemployment Homelessness, chronic unemployment

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} Regimen compliance is proximal

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addiction

High RiskHigh Risk Low RiskLow Risk

High High NeedsNeeds

Low Low NeedsNeeds

Risk & Needs MatrixRisk & Needs Matrix


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Low Low NeedsNeeds

Accountability,Accountability,Treatment &Treatment &HabilitationHabilitation


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addiction



Low Low NeedsNeeds

TreatmentTreatment&&

HabilitationHabilitation



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addiction



Low Low NeedsNeeds

AccountabilityAccountability&&






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addiction



Low Low NeedsNeeds

PreventionPrevention AccountabilityAccountability

&&HabilitationHabilitation




Practice ImplicationsPractice Implications

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addiction



Low Low NeedsNeeds

Status hearingsStatus hearings Treatment & habilitationTreatment & habilitation ComplianceCompliance is proximal is proximal Restrictive consequencesRestrictive consequences Positive reinforcementPositive reinforcement Agonist medicationAgonist medication

Noncompliance hearingsNoncompliance hearings Treatment & habilitationTreatment & habilitation TreatmentTreatment is proximal is proximal

Positive reinforcementPositive reinforcement Agonist medicationAgonist medication

v.o.p. / status calendarv.o.p. / status calendar AbstinenceAbstinence is proximal is proximal Psychosocial habilitationPsychosocial habilitation Restrictive consequencesRestrictive consequences NoNo AA or MET AA or MET Antagonist medicationAntagonist medication

Secondary prevention Secondary prevention AbstinenceAbstinence is proximal is proximal NoNo AA or MET AA or MET Individual counselingIndividual counseling oror stratified groups stratified groups

Dispositions for Drug Dispositions for Drug OffendersOffenders

Diversion (ARD) Incarceration

Probation w/o verdict

Drug / DWI Courts

Intermediatesanctions

Low riskLow riskLow Low needsneeds

Low riskLow riskHigh High needsneeds

High riskHigh riskHigh High needsneeds High riskHigh risk

Low Low needsneeds

Risk ofRisk ofDangerousnesDangerousnesss

Ok, Mr. Big Shot . . .Ok, Mr. Big Shot . . .

PROVE IT!PROVE IT!

““Key Components”Key Components”

• Judicial status hearings

• Graduated sanctions & rewards

• Urine drug screens

• Drug abuse treatment

• Case management

• Nolle prosse or conditions-served

• Expunged record (diversion)

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addiction

(NADCP, 1997)(NADCP, 1997)


Judicial status hearings


• Urine drug screens


• Case management

• Nolle prosse or conditions-served


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(NADCP, 1997)(NADCP, 1997)

Matching DesignMatching Design

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High Risk Low Risk

Matched

Unmatched

Bi-Weekly(n = 42)

As Needed(n = 95)

As Usual(monthly)

(n = 50)

(n = 92)

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Week in Drug Court

% d

rug

-fre

e u

rin

e sa

mp

les

matchedlow-riskmatchedhigh-risknonmatchedhigh-risknonmatchedlow-risk

a

a

a

b

% Drug-free Urines by % Drug-free Urines by GroupGroup

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addiction

p p < .001< .001

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Week in Drug Court

% d

rug

-fre

e u

rin

e sa

mp

les


a

a

a

b


TRIscience

addiction

p p < .001< .001

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Week in Drug Court

% d

rug

-fre

e u

rin

e sa

mp

les


a

a

a

b


TRIscience

addiction

p p < .001< .001

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Week in Drug Court

% d

rug

-fre

e u

rin

e sa

mp

les


a

a

a

b


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addiction

p p < .001< .001

Drug-Positive Urines: 6 Drug-Positive Urines: 6 Mos.Mos.

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addiction

50%

8%

44%

64%

0%

20%

40%

60%

80%

100%

UA

Dru

g P

osit

ive

Matched Unmatched

Low riskHigh risk

* * p < .05

**

**

Graduation Rates: 12 Graduation Rates: 12 mos.mos.

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addiction

72% 75% 75%

56%

0%

20%

40%

60%

80%

100%

Gra

du

ati

on

Rate

Matched Unmatched

Low riskHigh risk

* * p < .05

**




• Urinalyses


• Case management

• Nolle prosse or time served


TRIscience

addiction

(NADCP, 1997)(NADCP, 1997)



Graduated sanctions & rewards

• Urinalyses


• Case management

• Nolle prosse or time served


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addiction

(NADCP, 1997)(NADCP, 1997)

Months of compliance

STANDARDREWARDS

1 Applause; hat / candle;

framed certificate; travel

2

3

4Applause; keychain;

certificate; ↓↓hearings & UA

5

6

7

8Applause; certificate; travel; ↓↓ hearings & UA

9

10

11

12 Grad ceremony; framed plaque; dismissal

Total

RewardsRewards


STANDARDREWARDS

ESCALATING REWARDS


framed certificate; travel$5.00 gift certificate

2 $10.00 gift certificate




$20.00 gift certificate











Total $390.00

RewardsRewards


STANDARDREWARDS

ESCALATING REWARDS

THINNING REWARDS


framed certificate; travel$5.00 gift certificate


2 $10.00 gift certificate $30.00 gift certificate




$20.00 gift certificateEligible for $50.00 gift certificate if compliant one additional month


6 $30.00 gift certificateEligible for $50.00 gift certificate if compliant one additional month



$40.00 gift certificateEligible for $75.00 gift certificate if compliant one additional month


10 $50.00 gift certificateEligible for $125.00 gift certificate if compliant two additional months

11 $55.00 gift certificateEligible for $125.00 gift certificate if compliant one additional month


$60.00 gift certificate$125.00 gift certificate

Total $390.00 $390.00

RewardsRewards

# Drug-Free Urines (13 mos.)# Drug-Free Urines (13 mos.)

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addiction

33.5 34.837.6

0

10

20

30

40

50

60

To

tal D

rug

-Fre

e U

rin

es

As Usual Escalating Thinningn=61n=61 n=60n=60 n=60n=60

p = n.s.

Mean % Sessions AttendedMean % Sessions Attended

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addiction

87%82%

88%

0%

25%

50%

75%

100%

As Usual Escalating Thinningn=61n=61 n=60n=60 n=60n=60

p = n.s.

Mean % Drug-Free UrinesMean % Drug-Free Urines

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addiction

77%

82%84% 84%

90%

80%

60%

70%

80%

90%

As Usual Escalating Thinning

High risk

Low risk

*p < .05n=3n=344

n=2n=299

n=3n=344

n=2n=299

n=2n=266

n=2n=244

Remaining ConcernsRemaining Concerns• Measurement errorMeasurement error

• DissimulationDissimulation

• Treatment needs vs. supervision needs Treatment needs vs. supervision needs

• Changing circumstancesChanging circumstances

• Non-compliance vs. non-responsivenessNon-compliance vs. non-responsiveness

• Individualized vs. standard responsesIndividualized vs. standard responses

ADAPTIVE INTERVENTION


Baseline Risk Assessment



BI-WEEKLY COURT HEARINGS

High RiskHigh Risk


AS-NEEDED COURT HEARINGS





Monthly Progress

Assessments






Monthly Progress

Assessments





NON-COMPLIANTNON-COMPLIANT ≥ 2 missed counseling sessions

and/or ≥ 2 missed urine specimens

If As-Needed:

BI-WEEKLY COURT

HEARINGS


Monthly Progress

Assessments







If As-Needed:

BI-WEEKLY COURT

HEARINGS


If Bi-Weekly:

JEOPARDY CONTRACT

Monthly Progress

Assessments







If As-Needed:

BI-WEEKLY COURT

HEARINGS


If Bi-Weekly:

JEOPARDY CONTRACT

Monthly Progress

Assessments







NON-RESPONSIVENON-RESPONSIVE

≥ 2 drug-positive urines

If As-Needed:

BI-WEEKLY COURT

HEARINGS


INTENSIVE CLINICAL CASE MANAGEMENT

If Bi-Weekly:

JEOPARDY CONTRACT

Monthly Progress

Assessments









If As-Needed:

BI-WEEKLY COURT

HEARINGS



If Bi-Weekly:

JEOPARDY CONTRACT

Monthly Progress

Assessments









RESPONSIVE & RESPONSIVE & COMPLIANTCOMPLIANT

If As-Needed:

BI-WEEKLY COURT

HEARINGS



If Bi-Weekly:

JEOPARDY CONTRACT

CONTINUE AS PREVIOUSLY

ASSIGNED

Monthly Progress

Assessments










If As-Needed:

BI-WEEKLY COURT

HEARINGS






If Bi-Weekly:

JEOPARDY CONTRACT

CONTINUE AS PREVIOUSLY

ASSIGNED

Monthly Progress

Assessments


Baseline Risk Assessment Low RiskLow RiskHigh RiskHigh Risk




Graduated: 20 WeeksGraduated: 20 Weeks

33%

0%

60%

38%

50%

21%

0%

20%

40%

60%

80%

High Risk Low Risk Total

Adaptive

As-Usual

p = .14ES = 0.6 (moderate)

n=6n=6 n=6n=6 n=10n=10 n=16n=16n=8n=8 n=14n=14

On Warrant StatusOn Warrant Status

17%

50%

10% 13% 13%

29%

0%

20%

40%

60%

80%


Adaptive

As-Usual


n=6n=6 n=6n=6 n=10n=10 n=16n=16n=8n=8 n=14n=14

% Drug-Free Urines% Drug-Free Urines

48%

40%

74%

54%

64%

48%

0%

20%

40%

60%

80%


Adaptive

As-Usual


n=6n=6 n=6n=6 n=10n=10 n=16n=16n=8n=8 n=14n=14

Ultimately GraduatedUltimately Graduated

79%88%

0%

20%

40%

60%

80%

100%

Adaptive As-Usual p = .43ES = 0.12 (small)

Days to GraduationDays to Graduation

0

40

80

120

160

200

240

280

Adaptive As-Usual

161.79

(73.75)

277.91277.91(168.9(168.9

3)3)

p = .03ES = 0.92 (large)

Days to Case ResolutionDays to Case Resolution

0

40

80

120

160

200

240

280

320

Adaptive As-Usual

171.50

(74.74)

307.64307.64(194.1(194.1

8)8)

p = .01ES = 0.96 (large)

Response OrderedResponse Ordered

31%

88%

0%

20%

40%

60%

80%

100%

Adaptive As-Usual

Days to a ResponseDays to a Response

89.67 (79.61)

16.25 (24.66)

0

20

40

60

80

100

Adaptive As-Usual

Cost ImplicationsCost Implications

• Avg. annual cost per participant Avg. annual cost per participant **– administration =administration = $ 4,000.00 $ 4,000.00 – outpatient treatment =outpatient treatment = + + $ 7,000.00$ 7,000.00

$11,000.00$11,000.00• Resolution in 4 fewer mos. Resolution in 4 fewer mos. ÷ ÷ 1/3 yr. 1/3 yr. • Potential costs savings = Potential costs savings = $ 3,700.00$ 3,700.00

* * Urban Institute, Urban Institute, 20082008

Cost ImplicationsCost Implications

• Avg. annual cost per participant Avg. annual cost per participant **– administration =administration = $ 4,000.00 $ 4,000.00 – outpatient treatment =outpatient treatment = + + $ 7,000.00$ 7,000.00

$11,000.00$11,000.00• Resolution in 4 fewer mos. Resolution in 4 fewer mos. ÷ ÷ 1/3 yr. 1/3 yr. • Potential costs savings = Potential costs savings = $ 3,700.00$ 3,700.00

Per participant per Per participant per year!year!

* * Urban Institute, Urban Institute, 20082008

SummarySummary

• One size does One size does notnot fit all fit all

• Drug courts are best suited for high risk Drug courts are best suited for high risk and high needs offendersand high needs offenders

• When possible, separate court calendars When possible, separate court calendars and treatment tracks should be held for and treatment tracks should be held for high risk vs. low risk clientshigh risk vs. low risk clients

• You may need to be nicest to the clients You may need to be nicest to the clients you might like the leastyou might like the least

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Summary (cont.)Summary (cont.)

• Adaptive algorithms consistently Adaptive algorithms consistently outperform individualized professional outperform individualized professional judgmentjudgment

• Better outcomes in less timeBetter outcomes in less time

• Time = $$$$!Time = $$$$!

References References

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addiction

Marlowe, DB et al. (2008). Adaptive interventions in drug court: A pilot Marlowe, DB et al. (2008). Adaptive interventions in drug court: A pilot experiment. experiment. Criminal Justice Review, 33Criminal Justice Review, 33, 343-360., 343-360.

Marlowe, DB et al. (in press). Adaptive interventions may optimize Marlowe, DB et al. (in press). Adaptive interventions may optimize outcomes in drug courts: A pilot study. outcomes in drug courts: A pilot study. Current Psychiatry ReportsCurrent Psychiatry Reports..

Marlowe, DB et al. (2007). Adapting judicial supervision to the risk level Marlowe, DB et al. (2007). Adapting judicial supervision to the risk level of drug offenders: Discharge and six-month outcomes from a of drug offenders: Discharge and six-month outcomes from a prospective matching study. prospective matching study. Drug & Alcohol Dependence, 88SDrug & Alcohol Dependence, 88S, 4-13., 4-13.

Marlowe, DB et al. (2006). Matching judicial supervision to clients’ risk Marlowe, DB et al. (2006). Matching judicial supervision to clients’ risk status in drug court. status in drug court. Crime & Delinquency, 52Crime & Delinquency, 52, 52-76. , 52-76.

AcknowledgmentAcknowledgment

National Institute on Drug AbuseNational Institute on Drug Abuse

Grant #R01-DA-13096

Douglas B. Marlowe, J.D., Ph.D. Treatment Research Institute at the University of Pennsylvania TRI science addiction Targeting Dispositions by Risks &

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